New NEJM series encourages doctors to take on the 'structural determinants' of health

Social determinants of health are becoming increasingly mainstream.

From health plans to health lawyers to Secretary Alex Azar, seemingly everyone in the healthcare realm now acknowledges that social determinants are a legitimate cause of poor health outcomes and health disparities and, more importantly, need to be addressed.

Now a new series in the New England Journal of Medicine is encouraging physicians to think beyond the social determinants of health to address the "structural determinants" of health.

While social determinants are “the seemingly static characteristics that mark inequalities,” structural determinants are “the social, political, and economic forces that drive these inequalities in the first place.”

For example, if income is a social determinant, a corresponding structural determinant would be an economic policy that benefits the wealthy and harms the poor. Income often predicts health status, but helping low-income people with poor health outcomes would require changing the policy. 

Similarly, structural determinants include broader societal forces like sexism and racism. 

Physicians face major barriers in addressing these forces, according to an introductory article, which appears in the journal’s “Medicine and Society” section. First, they need tangible direction about how to understand and intervene in structural determinants, which the social science literature has not provided thus far.

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Second, they need a paradigm shift.

“Structural social forces may seem too large and entrenched to be altered—a perception that reinforces the assumption that they lie outside the purview of clinical medicine,” the article says.

The new series hopes to teach physicians how to “diagnose” and respond to structural determinants. The first case study in the series involves a 55-year-old man in Los Angeles who is chronically homeless and has schizophrenia. He utilizes the nearest emergency department frequently but has received little in the way of psychiatric care; those who evaluated him alternately suspected he was not homeless, did not have schizophrenia, and was not worth admitting again.

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Authors Joel T. Braslow, M.D., Ph.D., and Luke Messac, M.D., Ph.D., attribute this problem to structural forces like housing costs, as well as the “demedicalization” of psychiatric conditions. In recent decades, physicians have come to view mental health issues as a byproduct of individual circumstances and social conditions, rendering it outside of their control. However, they say, it is critical for the medical world to acknowledge both.

Bringing it back to the case study, Braslow and Messac write, “We have seen not only the abdication of medical responsibility for the life circumstances of severely psychotic people, but also a growing acceptance of homelessness and incarceration as legitimate fates for people whose psychotic behavior violates social norms.”

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Physicians can and must view social ills as within the scope of their practice. Only by doing so can they design and implement interventions and improve patient outcomes, Braslow and Messac say.  

Medicine’s best hope may be the next generation of physicians. “Adding a basic competency in understanding how social forces affect our patients’ health can help physicians to find more opportunities to intervene on their behalf,” the authors write. 

The case study reflects this, too. The patient was arrested, charged with a felony, and imprisoned. But a group of psychiatry residents at UCLA are working to create a public clinic for homeless people with serious mental health conditions. In addition to acute care, the clinic will guide patients toward stable housing and regular health services.